- Email: [email protected]
A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion
Abstracts
454 A Case of Aortic Coarctation Presenting with Intracranial Microhaemorrhages F. Lee 1,∗ , I. Shiekh 2 , S. Shipton 3 , R. Clugston 2 , A. Abraham 1,2 , M. Schlaich 1 1 Royal
Perth Hospital, Perth, Australia Stanley Hospital, Perth, Australia 3 Princess Margaret Hospital, Perth, Australia 2 Fiona
A 21-year-old lady presented with headaches in the absence of other cardiac symptoms to her primary care physician. Electrocardiogram showed sinus rhythm with incomplete right bundle branch block. Ambulatory blood pressure (BP) monitoring confirmed grade 1 hypertension with 24-hour average of 136/97 mmHg, maximal systolic BP of 203 mmHg and maximal diastolic BP of 130 mmHg. Biochemical screen was unremarkable for secondary causes of hypertension. Abdominal imaging revealed normal kidneys and adrenal glands. Echocardiogram showed a non-dilated, well contracting left ventricle with concentric remodelling. She was commenced on lercanidipine, hydrochlorothiazide and olmesartan. Despite medical therapy, she developed post-coital headaches. MRI head demonstrated microhaemorrhages in bilateral basal ganglia. Further imaging including CT coronary angiogram (Fig. 1) and cardiac MRI (Fig. 2) demonstrated post-ductal coarctation (white arrows) with minimum diameter of less than 5 mm. Coronary artery and aortic arch anatomy were conventional. There was dilatation of the aortic arch branch vessels and bilateral internal mammary arteries. She subsequently underwent successful percutaneous stenting of the aortic coarctation with a 4 × 16 mm covered stent,
Fig. 1.
S241
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Fig. 2.
with single inflation to 18 atm. Within two months, her ambulatory BP profile returned to normal levels without the need for antihypertensive medication. http://dx.doi.org/10.1016/j.hlc.2017.06.455 455 A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion H. Klimis 1,2,3,∗ , M. Altman 1 , T. Tan 1,2,5 , S. Natividad 1 , R. Abraham 1 , L. Thomas 1,2,4 1 Department
of Cardiology, Westmead Hospital, Sydney, Australia 2 University of Sydney, Sydney, Australia 3 The George Institute for Global Health, Sydney, Australia 4 University of New South Wales, Sydney, Australia 5 Blacktown Mount Druitt Hospital, Sydney, Australia A 33-year-old male presented to emergency with right sided pleuritic chest pain, exertional dyspnoea, and lower limb oedema over the preceding 2 months. There were no other significant cardiac or medical problems and no regular medications. He was tachycardic (130bpm) but normotensive, tachypneoic (30 min) with normal saturation. Chest x-ray showed marked cardiomegaly; urgent transthoracic echocardiogram (TTE) demonstrated a very large global pericardial effusion with diastolic RV collapse and echocardiographic evidence of tamponade. Urgent pericardiocentesis removed 2L of straw coloured fluid via the subxiphoid approach. Despite drainage the patient had persistent dyspnoea and was hypotensive. Progress TTE on day 2 showed a moderate (22 mm) residual pericardial effusion with no evidence of tamponade, however the RV was moderately dilated (base 54 mm) with severely impaired segmental systolic dysfunction. The RV basal segment was akinetic with a hyperkinetic mid-apex (McConnell’s sign). LV size was normal with mildly
Abstracts
S242
impaired systolic function. CTPA showed an incidental large anterior mediastinal mass (10 × 18 × 14 cm) and was highly suspicious for lymphoproliferative disease. There was no pulmonary embolus and no features of pulmonary arterial hypertension apart from dilated RV. Reaccumulation of the pericardial effusion necessitated creation of a pericardial window. Biopsy of the mediastinal mass confirmed Hodgkin’s lymphoma (classical nodular sclerosing type). Staging PET and CT abdomen/pelvis showed stage II disease, and treatment with BEACOPP was commenced. This case highlights the importance of gradual decompression of symptomatic pericardial effusion to avoid RV failure which could be caused by myocardial stunning or by a variant reperfusion injury as a consequence of pericardiocentesis. http://dx.doi.org/10.1016/j.hlc.2017.06.456 456 A Comparison Between Qualitative Assessment of Left Ventricular Size and Systolic Function with Quantitative Measures M. Stephens ∗ , F. Fernandez, P. Stoodley, G. Gan, A. Bhat, S. Eshoo, C. Hsu, T. Tan Department of Cardiology, Blacktown Hospital, Sydney, Australia Background: Assessment of left ventricular (LV) function and volumes is the cornerstone of cardiac diagnostics. In a busy clinical service, echocardiographers frequently estimate overall size and contractility without formal quantification. While visual estimation of LV systolic function, even after limited training, has been proven to be reasonably accurate, qualitative assessment of LV size and function has significant inter-observer variability and is related to interpreter skill level. Methods: 25 subjects were asked to visually assess LV size, systolic function and LVEF for 11 test patients with varying grades of LV size and systolic function. The blinded subjects comprised of cardiologists, cardiology advanced trainees, sonographers and sonographer students in a set time frame. All test subjects were blinded and parameters of interest were compared to 2D quantitative echo measurements and cardiac MRI. Results: The 25 subjects comprised 8 cardiologists, 3 advanced trainees, 7 sonographers and 7 sonography students. LV size and function was accurately assessed visually by only approximately half of the subjects with <40% providing an accurate assessment of LVEF. Severe grades of LV dilatation of systolic function were most accurately identified. However, mild and moderate grades of LV size and systolic function had the poorest scores regardless of image quality. Conclusion: The results highlight that the level of experience plays a significant role in the accuracy of qualitative assessments. Additionally, the need for quantitation of left ventricular size and systolic function particularly for the mild and moderate grades of severity is highlighted to ensure accurate interpretation.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
http://dx.doi.org/10.1016/j.hlc.2017.06.457 457 This abstract has been withdrawn
http://dx.doi.org/10.1016/j.hlc.2017.06.458 458 A Singularly Unique Problem in a Dual Pregnancy W. Peverill, W. Parsonage, S. Prasad ∗ Royal Brisbane and Women’s Hospital, Brisbane, Australia Unicuspid aortic valve is an extremely rare congenital cause of aortic stenosis occurring in around 0.02% of patients referred. We present a case of a 40-year-old female at 14 weeks’ gestation referred for progressive exertional dyspnoea. She was diagnosed with severe aortic stenosis secondary to unicuspid aortic valve disease and ultimately required balloon valvuloplasty to complete her pregnancy. Prior to conception our patient noted mild exertional dyspnoea which she had ascribed to her weight. Her twins were conceived via in vitro fertilisation due to difficulties achieving conception and were thus considered a ‘precious pregnancy’. During her pregnancy her symptoms progressed. Echo findings included a peak velocity 4.2 m/s across the aortic valve, mean gradient of 43 mmHg and a valve area of 0.9 cm. Her ascending aorta was dilated at 41 mm. Given the combination of severe aortic stensosis with aortopathy, at this point she was offered termination which she declined. A multidisciplinary team meeting was held and the options of medical management, balloon valvuloplasty and valve replacement were discussed. Ultimately the patient opted for balloon valvuloplasty due to the lower comparative risk of fetal demise. A team consisting of obstetricians, midwives, cardiothoracic surgeons and cardiologists was assembled for the balloon valvuloplasty at 28 weeks. Balloon valvuloplasty was performed successfully. Post valvuloplasty she became asymptomatic. She had a planned Caesarean-section which successfully delivered two healthy twins. This case is the first to describe unicuspid aortic valve stenosis in pregnancy and further illustrates the difficulties in managing severe aortic stenosis in the peripartum period. http://dx.doi.org/10.1016/j.hlc.2017.06.459
454 A Case of Aortic Coarctation Presenting with Intracranial Microhaemorrhages F. Lee 1,∗ , I. Shiekh 2 , S. Shipton 3 , R. Clugston 2 , A. Abraham 1,2 , M. Schlaich 1 1 Royal
Perth Hospital, Perth, Australia Stanley Hospital, Perth, Australia 3 Princess Margaret Hospital, Perth, Australia 2 Fiona
A 21-year-old lady presented with headaches in the absence of other cardiac symptoms to her primary care physician. Electrocardiogram showed sinus rhythm with incomplete right bundle branch block. Ambulatory blood pressure (BP) monitoring confirmed grade 1 hypertension with 24-hour average of 136/97 mmHg, maximal systolic BP of 203 mmHg and maximal diastolic BP of 130 mmHg. Biochemical screen was unremarkable for secondary causes of hypertension. Abdominal imaging revealed normal kidneys and adrenal glands. Echocardiogram showed a non-dilated, well contracting left ventricle with concentric remodelling. She was commenced on lercanidipine, hydrochlorothiazide and olmesartan. Despite medical therapy, she developed post-coital headaches. MRI head demonstrated microhaemorrhages in bilateral basal ganglia. Further imaging including CT coronary angiogram (Fig. 1) and cardiac MRI (Fig. 2) demonstrated post-ductal coarctation (white arrows) with minimum diameter of less than 5 mm. Coronary artery and aortic arch anatomy were conventional. There was dilatation of the aortic arch branch vessels and bilateral internal mammary arteries. She subsequently underwent successful percutaneous stenting of the aortic coarctation with a 4 × 16 mm covered stent,
Fig. 1.
S241
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Fig. 2.
with single inflation to 18 atm. Within two months, her ambulatory BP profile returned to normal levels without the need for antihypertensive medication. http://dx.doi.org/10.1016/j.hlc.2017.06.455 455 A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion H. Klimis 1,2,3,∗ , M. Altman 1 , T. Tan 1,2,5 , S. Natividad 1 , R. Abraham 1 , L. Thomas 1,2,4 1 Department
of Cardiology, Westmead Hospital, Sydney, Australia 2 University of Sydney, Sydney, Australia 3 The George Institute for Global Health, Sydney, Australia 4 University of New South Wales, Sydney, Australia 5 Blacktown Mount Druitt Hospital, Sydney, Australia A 33-year-old male presented to emergency with right sided pleuritic chest pain, exertional dyspnoea, and lower limb oedema over the preceding 2 months. There were no other significant cardiac or medical problems and no regular medications. He was tachycardic (130bpm) but normotensive, tachypneoic (30 min) with normal saturation. Chest x-ray showed marked cardiomegaly; urgent transthoracic echocardiogram (TTE) demonstrated a very large global pericardial effusion with diastolic RV collapse and echocardiographic evidence of tamponade. Urgent pericardiocentesis removed 2L of straw coloured fluid via the subxiphoid approach. Despite drainage the patient had persistent dyspnoea and was hypotensive. Progress TTE on day 2 showed a moderate (22 mm) residual pericardial effusion with no evidence of tamponade, however the RV was moderately dilated (base 54 mm) with severely impaired segmental systolic dysfunction. The RV basal segment was akinetic with a hyperkinetic mid-apex (McConnell’s sign). LV size was normal with mildly
Abstracts
S242
impaired systolic function. CTPA showed an incidental large anterior mediastinal mass (10 × 18 × 14 cm) and was highly suspicious for lymphoproliferative disease. There was no pulmonary embolus and no features of pulmonary arterial hypertension apart from dilated RV. Reaccumulation of the pericardial effusion necessitated creation of a pericardial window. Biopsy of the mediastinal mass confirmed Hodgkin’s lymphoma (classical nodular sclerosing type). Staging PET and CT abdomen/pelvis showed stage II disease, and treatment with BEACOPP was commenced. This case highlights the importance of gradual decompression of symptomatic pericardial effusion to avoid RV failure which could be caused by myocardial stunning or by a variant reperfusion injury as a consequence of pericardiocentesis. http://dx.doi.org/10.1016/j.hlc.2017.06.456 456 A Comparison Between Qualitative Assessment of Left Ventricular Size and Systolic Function with Quantitative Measures M. Stephens ∗ , F. Fernandez, P. Stoodley, G. Gan, A. Bhat, S. Eshoo, C. Hsu, T. Tan Department of Cardiology, Blacktown Hospital, Sydney, Australia Background: Assessment of left ventricular (LV) function and volumes is the cornerstone of cardiac diagnostics. In a busy clinical service, echocardiographers frequently estimate overall size and contractility without formal quantification. While visual estimation of LV systolic function, even after limited training, has been proven to be reasonably accurate, qualitative assessment of LV size and function has significant inter-observer variability and is related to interpreter skill level. Methods: 25 subjects were asked to visually assess LV size, systolic function and LVEF for 11 test patients with varying grades of LV size and systolic function. The blinded subjects comprised of cardiologists, cardiology advanced trainees, sonographers and sonographer students in a set time frame. All test subjects were blinded and parameters of interest were compared to 2D quantitative echo measurements and cardiac MRI. Results: The 25 subjects comprised 8 cardiologists, 3 advanced trainees, 7 sonographers and 7 sonography students. LV size and function was accurately assessed visually by only approximately half of the subjects with <40% providing an accurate assessment of LVEF. Severe grades of LV dilatation of systolic function were most accurately identified. However, mild and moderate grades of LV size and systolic function had the poorest scores regardless of image quality. Conclusion: The results highlight that the level of experience plays a significant role in the accuracy of qualitative assessments. Additionally, the need for quantitation of left ventricular size and systolic function particularly for the mild and moderate grades of severity is highlighted to ensure accurate interpretation.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
http://dx.doi.org/10.1016/j.hlc.2017.06.457 457 This abstract has been withdrawn
http://dx.doi.org/10.1016/j.hlc.2017.06.458 458 A Singularly Unique Problem in a Dual Pregnancy W. Peverill, W. Parsonage, S. Prasad ∗ Royal Brisbane and Women’s Hospital, Brisbane, Australia Unicuspid aortic valve is an extremely rare congenital cause of aortic stenosis occurring in around 0.02% of patients referred. We present a case of a 40-year-old female at 14 weeks’ gestation referred for progressive exertional dyspnoea. She was diagnosed with severe aortic stenosis secondary to unicuspid aortic valve disease and ultimately required balloon valvuloplasty to complete her pregnancy. Prior to conception our patient noted mild exertional dyspnoea which she had ascribed to her weight. Her twins were conceived via in vitro fertilisation due to difficulties achieving conception and were thus considered a ‘precious pregnancy’. During her pregnancy her symptoms progressed. Echo findings included a peak velocity 4.2 m/s across the aortic valve, mean gradient of 43 mmHg and a valve area of 0.9 cm. Her ascending aorta was dilated at 41 mm. Given the combination of severe aortic stensosis with aortopathy, at this point she was offered termination which she declined. A multidisciplinary team meeting was held and the options of medical management, balloon valvuloplasty and valve replacement were discussed. Ultimately the patient opted for balloon valvuloplasty due to the lower comparative risk of fetal demise. A team consisting of obstetricians, midwives, cardiothoracic surgeons and cardiologists was assembled for the balloon valvuloplasty at 28 weeks. Balloon valvuloplasty was performed successfully. Post valvuloplasty she became asymptomatic. She had a planned Caesarean-section which successfully delivered two healthy twins. This case is the first to describe unicuspid aortic valve stenosis in pregnancy and further illustrates the difficulties in managing severe aortic stenosis in the peripartum period. http://dx.doi.org/10.1016/j.hlc.2017.06.459